From North Africa to Italy: Seeking Refuge, Finding Suffering

ITALY 2011 © Mattia Insolera

MSF calls on Italian authorities to drastically improve conditions for refugees, asylum seekers and migrants fleeing North Africa, including Libya

Since the popular uprisings and violent confrontations that have shaken the Arab world began in December 2010, some 27,000 refugees, asylum seekers, and undocumented migrants from North Africa have arrived by sea on the southern Italian island of Lampedusa.

Italy 2011 © Mattia Insolera

MSF staff in Lampedusa, in southern Italy, tends to a new arrival from North Africa exhausted by the arduous journey.


Since last December, when popular uprisings and violent confrontations began to shake the Arab world, some 27,000 refugees, asylum seekers, and undocumented migrants have fled by sea from North Africa to the southern Italian island of Lampedusa. Most of the boats that made the journey originated in Tunisia, but increasing numbers are coming from Libya. On April 19, 760 people landed in Lampedusa in one of the largest single landings the island has ever seen.

Many of those who departed from Libya are actually sub-Saharan Africans from Eritrea, Somalia, Sudan, or Nigeria. Having already fled their own countries in search of better economic opportunities and a more secure environment, they were forced to flee once more due to the escalating conflict in Libya.

Italy 2011 © Mattia Insolera

Survivors of a three-day boat journey from Libya, part of the largest group of migrants ever to arrive on the island of Lampedusa, are transfered from the port to one of the area's reception centers.

Though the journey from North Africa to Lampedusa is often perilous, many deem it worthwhile because it represents their best hope of finding a way to earn a livelihood for themselves and their families away from the economic despair and rampant insecurity of their homelands. It comes with numerous risks, however. Some speak of having been victims of detention, rape, and torture, and of being targeted because they were foreigners. Unaccompanied minors and women traveling alone are particularly vulnerable.

The conditions awaiting these refugees and migrants on Lampedusa generally fail to meet the minimum standards for the reception of vulnerable persons, leading to additional suffering and uncertainty. The reception centers themselves are substandard. There is inadequate separation between men and women. There is a lack of access to information about the rights of migrants and refugees and a lack of care tailored to the most vulnerable groups, including victims of torture and violence, unaccompanied minors, and women.

Doctors Without Borders/Médecins Sans Frontières (MSF) has worked in Italy since 1999 at landing points and in open settings to provide medical care and mental health support to arriving refugees, asylum seekers, and migrants. The organization has repeatedly called attention to the appalling reception and living conditions facing this population upon their arrival—and its profound impact on their physical and mental health.

Since February 2011, MSF has conducted 765 medical consultations for migrants and refugees in Lampedusa and has provided them with a total of 4,500 hygiene kits and blankets. Seeing no improvement in the appallingly inadequate conditions[1], MSF is compelled to speak out again about the failure to provide assistance and protection to those fleeing from North Africa, many of whom have experienced violence and torture.

Given Lampedusa's history as a landing point for migrants, refugees, and asylum seekers, along with the dramatic events currently taking place in North Africa, the Italian authorities can anticipate significant numbers of new arrivals. It is therefore imperative that the country upholds its responsibility to provide adequate, humane reception conditions for people who have made the journey in order to survive or to escape violence.

The new arrivals on Lampedusa face vulnerability that goes beyond the need for medical care and material assistance. It is also the responsibility of the Italian state to ensure adequate reception conditions and provide information and access to legal procedures and protection.

“There was shooting every day, every night, it was very dangerous [in Libya]. Sometimes, they come house by house. You walk in the street, a car stop and then, someone behind you push you in the car and you disappear. I could not go out anymore. I took a boat to any country to save my life.”

—Nigerian man, 28, Piam Dem Pago Center, Italy, April 2011

“I arrived this morning; I was in the boat that sank. I was injured in the face when the boat took water. I really struggled to survive. And then the coast guards took us on their boat. They rescued the three of us, but many people did not make it.”

—Somali man, 17, Lampedusa, Italy, April 2011

“Some friends told me that if I get $900, I could leave on a boat. I spent two days waiting for a seat on the boat. One group left first, but it was too windy and their boat broke down 8 kilometers (4.8 miles) from the coast. We had to wait all together again. They came back; they had found a bigger boat for all of us. We were 300 persons. It took us four days from Tripoli to reach Italy. It was very difficult on that ship. Water started to enter in the boat; we were very scared. They came with the Italian authorities to rescue us. A woman gave birth on the boat. We had nothing to clean the baby with.”

—Eritrean woman, 22, Mineo, Italy, April 2011

Poor Conditions in Centers Increase Vulnerability

For many years, MSF has been calling attention to the appalling reception conditions in Italy and their impact on physical and mental health. With the increased influx of refugees and migrants from North Africa, Italy is responsible for ensuring humane conditions for new arrivals and providing access to legal procedures and protection.

Italy 2011 © Mattia Insolera

MSF distributed water and essential relief items to the newly arrived migrants from Libya in Lampedusa.

Migrants, asylum seekers, and refugees fall into distinct legal categories with different rights. Many of those who left Libya or Tunisia in recent months have special needs for assistance and safety. These include particularly vulnerable persons, such as children, unaccompanied minors, pregnant women, the disabled, and victims of torture and violence, including sexual violence. However, they are all funneled into the same inadequate system and facilities when they arrive in Italy.

The European Council Directive establishes minimum standards for the reception of asylum seekers (2003/9/EC) and explicitly states that “reception of groups with special needs should be specifically designed to meet those needs." Vulnerable asylum seekers require priority treatment according to their needs, including systematic identification of vulnerability at arrival, specialized health care if necessary, and psychosocial care addressing the short- and long-term effects of sexual and physical violence.[2] This should be applied regardless of the country from which they arrived, be it Libya, Tunisia, or elsewhere.

MSF is deeply concerned about victims of violence among the groups the organization has assisted in Italy. Many have been directly affected by violence and war in North Africa or have been firsthand witnesses of violence. Some report suffering sexual abuse and torture, both in their home country or in the other countries where they have gone to survive and seek refuge. Most have experienced extreme hardships and suffering from the day they left their country of origin to their eventual arrival in Italy.

“I tried two times to come to Italy. The first one was in August 2009. Our boat was already out at sea, but a Libyan boat arrived and took us back to Libya. For this reason I was jailed for about one month in prison near Tripoli airport. Conditions were extremely difficult. We were 65 people in a rectangular room measuring five-by-eight meters. We had three meals a day, but we only had tea, rice, and bread. We did not have water and so we had to drink water from the two toilets we had for 65 people.”

—Somali man, 20, Caltanissetta, Italy, April 2011

 “I spent eight months in a detention center in Zliten [in Libya]. They put us in a room that had no window and locked the door. It was horrible. We were 13 women in one room. We were sleeping there, going to the toilet there, taking water there, washing and drying our clothes there. We were lying on the floor and they beat us with plastic sticks. We cried and cried! They took all our belongings, our cell phones, the little money we had left. From the little window in the door we sometimes saw the guards beat the men. They hit them on the bottoms of their feet, they screamed so much, and then they threw water on their heads. When we were watching that, we were all crying, they were our brothers, our men.”

—Eritrean woman, 22, Mineo, Italy, April 2011

Women and children in Italian reception centers must be housed in areas where their safety and well-being is ensured. Many women traveling alone who were placed in  reception centers told MSF that there was no effective separation from men, and they feared abuse despite the strong presence of police. Due to the lack of privacy and security, women reported being too afraid to sleep, change clothes, or even go to the toilet alone.

“Yesterday night, a man followed me to the toilets. I pushed him, I ran away, and I screamed. Men jump over the wall and enter in our room. We are afraid at night; we cannot sleep. The police do not do anything.”

—Tunisian woman, 67, Lampedusa, Italy, April 2011

“I don’t have a husband anymore; I have nobody to protect me. We left because we were not safe anymore, and here it is not better. Since we arrived in this center, we never relax, we are afraid of the men entering in our room. We do not change our clothes. We do not dare to undress because men are outside looking at us at the windows.”

—Tunisian woman, 35, Lampedusa, Italy, April 2011

MSF has also witnessed children and unaccompanied minors being kept in closed centers in Lampedusa due to the lack of designated structures to shelter them—a stark contravention of the children's best interests.[3] According to European standards, “minors should be placed with adult relatives, foster families, in accommodation centers with special provisions for minors, or in other accommodations suitable for minors.”[4]

While conducting medical and mental health assessments in newly created reception centers in Kinisia, Manduria, and Mineo, MSF teams observed that the refugees and asylum seekers had received no clear information about how they might access legal resources or about their practical situation and future options. In some centers, there were serious gaps in the provision of basic and legal services, which caused significant anxiety, frustration, and uncertainty. Initial mental health assessments of the new arrivals pointed to the risk of widespread depression and hopelessness in response to their uncertain situation. These effects are aggravated by the lack of information about legal procedures in Italy. MSF witnessed the same dynamics in 2009, when our work in Maltese detention centers for undocumented migrants and asylum seekers revealed high rates of depression, anxiety, and post traumatic stress disorder[5].

“This place is not good. Here we are seven women, all from Eritrea. Yesterday a man came at 3am. He entered in the other girls’ room. He started to speak in Arabic. They screamed, so he left. They were so afraid that they came to our room and slept on the floor. We did not sleep, we waited and listened. We are afraid. I went to the police this morning to complain but they told me to come back, they are too busy. Men are drinking outside. There is no security here.”

— Eritrean woman, 22, Mineo, April 2011

Avoid Repeating Same Mistakes

MSF has provided assistance to refugees and migrants in Italy, Malta, Greece, France, and Spain—as well as in Morocco and Tunisia—since 1999. From 2002 to 2009, MSF worked on the island of Lampedusa and the southern coast of Sicily, the most frequent landing points for regular arrivals of migrants and refugees. MSF has long documented the far-reaching impact of insufficient reception and living conditions on the physical and mental health of asylum seekers and migrants, based on our work in southern Europe.

In May 2009, new government policies, in particular the “Friendship Pact”[6] between Italy and Libya, curbed the influx of refugees and migrants. After arrivals by boat decreased in Lampedusa, MSF withdrew its team from the island and publicly expressed its fears for the health and lives of the refugees and migrants forced back to Libya.[7]

This past February, in response to the arrival of thousands of migrants, refugees, and asylum seekers from Tunisia and Libya, MSF restarted its medical activities on the island. Between February 14 and April 21, 2011, MSF medical teams carried out 765 consultations with refugees and migrants in need of care upon arrival at the docks in Lampedusa. MSF likewise provided new arrivals with basic necessities, such as hygiene materials and blankets.

Italy 2011 © Mattia Insolera

MSF medical staff treats a migrant after he survived a three-day boat journey from Libya.

Generally, new arrivals suffered from seasickness, dehydration, hypothermia, and generalized body pain, such as headaches or abdominal pain. At the peak of arrivals in March, 3,000 migrants slept on the docks in Lampedusa for several days, sharing 16 chemical toilets and having access to only 1.5 liters of water per day. This was completely unacceptable, and though conditions have improved somewhat since then, it is clear that the situation facing migrants, refugees, and asylum-seekers in Lampedusa and other centers across Italy today continues to compound suffering and increase vulnerability. 

MSF Urgently Calls on Italian Authorities to Prepare For Influx

“Since the beginning of the fighting, things got more and more difficult. Still, I wanted to try to remain in Libya because I was really afraid of traveling to Lampedusa on a fishing boat. But on March 17, I decided that time was up for me in that country. I was working in a restaurant and went to deliver food with my Moroccan colleague. A pick-up driving past with armed men shot at us. My Moroccan friend was shot in the chest. He died right there, in front of me. The pick-up made a U-turn to come back and kill me. I ran back to the restaurant. There were four black people working in the kitchen of the restaurant, including me. All of us decided to leave immediately. As a black person in Tripoli you cannot move around. You are in danger. I still have many friends in Tripoli that want to leave.”

—Gambian man, 29 years old, Lampedusa, Italy, April 2011

People fleeing Libya describe the terrifying situation of migrants and refugees still trapped by the violence. Countless people are still searching for ways to flee to more secure environs, or simply to survive. People arriving in Italy from other countries in Africa also speak of their flight from violence, fear and extreme poverty.

In view of the regular and longstanding pattern of arrivals of refugees, migrants, and asylum seekers in southern Italy from North Africa, MSF is highly concerned about the lack of concrete preparation for continued arrivals in the coming weeks and months. Despite the generally predictable nature of arrivals, reception centers currently take an unacceptably ad hoc approach that barely covers basic needs and does not adequately ensure the safety and security of new arrivals, particularly for the most vulnerable, including those who have experienced violence.

The stories told by refugees and migrants reveal the extreme mental and physical hardship they have escaped and endured. Upon their arrival in Italy, poor reception conditions expose them to further suffering and renewed vulnerability and uncertainty.

MSF calls on the Italian authorities to develop a concrete strategy to ensure an adequate, humane reception for all migrants and asylum seekers already in the country or soon to arrive, but particularly for the most vulnerable, including women, children, unaccompanied minors, and victims of violence.

The Italian government must take concrete measures to better receive, assist, and protect these people. The measures should include:

  • Ensuring appropriate medical and mental health support
  • Improving overall conditions in reception centers
  • Ensuring that minimum standards for reception of vulnerable people are upheld, including:
    • systematic identification of vulnerable persons
    • specific attention to victims of torture and violence
    • separate, adequate living areas for unaccompanied minors and women traveling alone, regardless of time spent in any one location
  • Providing systematic information to all new arrivals on asylum procedures and practical arrangements (e.g. transfer to other centers)
  • Developing a concrete plan for the reception of the continued arrival of significant numbers of refugees and migrants in the coming months

The 27,000 people who have arrived in southern Italy since January 2011 will undoubtedly be followed by others in the coming months. It is time for Italy to fully prepare itself and better fulfill its responsibilities and obligations towards the refugees, asylum-seekers, and migrants who reach its shores.

  1.   MSF teams assessed the general reception conditions from 3rd to 10th of April in Kinisia (Trapani), Pian del lago (Caltanissetta), Mineo (Catania),Manduria (Taranto), Restinco (Brindisi), Bari Palese (Bari), Borgo Mezzanone (Foggia) centers; and mental health needs from 11th to 13th of April in Mineo (Catania) and Pian Del Lago (Catlanissetta) centers. Testimonies were collected during this same period.
  2.   Article 20 of Directive 2003/9/EC : “Victims of torture and violence: Member States shall ensure that, if necessary, persons who have been subjected to torture, rape or other serious acts of violence receive the necessary treatment of damages caused by the aforementioned acts.”
      Art. 15.2 of Directive 2003/9/EC of 27 January 2003  : “Health care: Member States shall provide necessary medical or other assistance to applicants who have special needs.”
  3.   As stated in the UN Convention on the Right of the Child.
  4.   See Report from the Commission to the Council and to the European Parliament on the application of Directive 2003/9/EC of 27 January 2003 laying down minimum standards for the reception of asylum seekers and Art. 17 of Directive 2008/115/EC OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL of 16 December 2008 on common standards and procedures in Member States for returning illegally staying third-country nationals.
  5.   MSF Press Release: Bearing the brunt of migration policies: MSF urges European governments to respect life, dignity and healthcare of migrants and asylum seekers In Malta, MSF consultations with the detainees revealed the extreme mental health impact as a result of the harsh journey to Malta and their subsequent confinement in detention centers. One-third of the patients consulted showed symptoms of depression and one-quarter were suffering from anxiety. Nine percent were diagnosed with post-traumatic stress disorder.
  6.   “The Treaty of Friendship, Partnership and Cooperation between the Italian Republic and Great Socialist People’s Libyan Arab Jamahiriya” has been signed on August 30, 2008.
  7.   MSF Press Release: “Fears For Migrants Forced Back To Africa”